Connect Gold 2500 Indiv Med Deductible
Cigna HealthCare of Arizona, Inc
Plan overview
Medical deductible
Individual: $2500
Family: $5000
Per Person: $2500
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $8200
Family: $16400
Per Person: $8200
Office visit
Primary Doctor
CoPay: $5.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Refer to the policy for more information about Virtual Care Services.
Specialist
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: This benefit applies to Specialist Office Visits. All other Outpatient Services are covered at the Outpatient professional services benefit. Please refer to the Policy for more information.
Prescription drug information
Preferred brand drugs
CoPay: $55.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: You pay a copayment for each 30 day supply. Limited to a 30-day supply at a Participating Pharmacy or up to a 90-day supply at a Designated 90-day Pharmacy. Refer to the prescription drug list for more information.
Non preferred brand drugs
CoPay: Not Applicable
CoInsurance: 49.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Limited to a 30-day supply at a Participating Pharmacy or up to a 90-day supply at a Designated 90-day Pharmacy. Refer to the prescription drug list for more information.
Generic drugs
CoPay: $3.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: You pay a copayment for each 30 day supply. Cost sharing shown applies to Tier 1-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 2-Generic Drugs, which may apply a higher cost share. Limited to a 30-day supply at a Participating Pharmacy, or up to a 90-day supply at a Designated 90-day Pharmacy. Refer to the prescription drug list for more information.
Specialty drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Including other high cost drugs. Limited to a 30-day supply at a Participating Pharmacy or up to a 30-day supply at a Designated 90-day Pharmacy. Refer to the prescription drug list for more information.
Inpatient coverage
Hospital services
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Inpatient services
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Out-of-Network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered.
Urgent care facility
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Out-of-Network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered. See Policy for telehealth coverage details.
Maternity
Labor and delivery hospital stay
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal office visit
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Vision
Routine Eye Exams for Children
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 1
Limit Unit: Visit(s) per Year
Benefit Explanation: Children up to age 19.
Major dental care
Routine dental checkups for children
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).